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Defeating re-emerging Alkhurma hemorrhagic fever virus outbreak in Saudi Arabia and worldwide

E. Tambo,Ashraf G El-Dessouky

Published 2018 in PLoS Neglected Tropical Diseases

ABSTRACT

Sporadic incidence and prevalence of Alkhurma hemorrhagic fever virus (AHFV) (family Flaviviridae; genus Flavivirus) in Saudi Arabia (KSA) is profiled periodically. The virus, which is related to tick-borne encephalitis (TBE) complex and is genetically closely related to Kyasanur Forest disease virus (KFDV), was primarily identified in KSA in November and December 1995 based on isolation from the blood of 6 male butchers aged 24 to 39 years old and residents in the Jeddah province, of whom 4 recovered completely [1,2]. Since then, new outbreaks with sporadic incidences have been reported in KSA, and subsequent cases of AHF have been documented among tourists in Egypt and Djibouti, extending to India, Europe, and beyond, suggesting that AHFV infections’ geographic distribution is underreported [3,4,5]. According to the Saudi Ministry of Health statistical yearbook for the year 2016 (1437 H), 38 new infection cases were reported in 2016 from the Makkah and Najran provinces. Twenty-four of the infections affected those aged 15 to<45 followed by 13 cases among those aged 45 [6]; meanwhile, a low incidence rate was documented among Saudi citizens compared to foreigners/expatriate workers, with the highest infection rate during the months of March, July, and September yearly [7]. The disease infection pattern revealed that the reported cases were 58, 59, 70, 60, and 38 for 2012, 2013, 2014, 2015, and 2016, respectively, per 100,000 population in KSA [7]. AHFV cases have been epidemiologically linked to direct and indirect exposure (to infected blood and/or organs of slaughtered animals and consumption of infected raw milk. Assumptions of infection transmission via arthropod bites, including Hyalomma spp. ticks and migratory birds and/or small and/or larger mammals (e.g., cattle, buffaloes, camels), have been reported in the literature [8,9,10] even though this assumption was not supported by other previous studies’ reports [11]. A retrospective analysis of AHFV laboratory-confirmed cases for 3 consecutive years (2009–2011) reported that the most common signs and symptoms were fever (reported by about 96% of all cases, with more than 90% having body temperatures above 37.0 ̊ C), malaise (about 60%), and chills (about 40%) [8,10]. Clinical manifestations also included pain disorders and headache (60%), myalgia (44%), retro-orbital pain (16%), gastrointestinal symptoms (99%), anorexia (62%), nausea (60%) and vomiting (53%), and diarrhea (12%). Whereas less than 10% of the patients reported any symptoms of the central nervous system, the most common symptoms were disorientation (5.4%), hallucination (4.3%), and convulsion (4.3%) [8,9,10]. The most common hemorrhagic manifestations were purpura and epitasis (5%), whereas the least was menorrhagia (2.2%), and the overall case

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